Provider Demographics
NPI:1619068426
Name:BUCKLEY, TIFFANY A (CPHT, CPB)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:CPHT, CPB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4734 S 252ND WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-4319
Mailing Address - Country:US
Mailing Address - Phone:580-761-5034
Mailing Address - Fax:
Practice Address - Street 1:4734 S 252ND WEST AVE
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-4319
Practice Address - Country:US
Practice Address - Phone:580-761-5034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT2081183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT-2081OtherOK BOARD OF PHARMACY
OK100700590Medicaid